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Last Updated Wednesday June 21 2017 09:08 AM IST

The fine print your health insurer won’t tell you

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If you are planning to buy a health insurance policy, better consult Mahendran, Aniyamma or Molly. The laborer from Mattupetty, the housewife from Vayalikkada and the senior citizen from Kurisummoodu know a thing or two about insurance companies’ tall claims.

Molly has paid about Rs 72,000 to her insurer over ten years but had not claimed anything in return until she had to undergo an emergency surgery. She had insurance cover of Rs 3.25 lakh including cumulative bonus.

The surgery cost her about Rs 46,000 but she was granted only Rs 17,000 by the insurer. The company justified its action by saying that the room rent was beyond the limit set by its rules. At the same time, they had also cut down on other items which were permissible.

When she checked with the third-party administrator (TPA), the executive would merely say that they were just following the company rules. The old woman did not have any energy left to pursue the case.

Aniyamma, wife of a doctor at Vayalikkada, broke her leg when she slipped inside her house. She did not go to any super specialty hospitals for treatment but preferred to go to an ordinary private hospital. Her husband claimed the expenses under a policy, which covered both of them since 2002.

He was shocked to see the insurer slashing the amount across almost all items. When he protested, the company sent him 23 pages of fine print. The jargon-filled document was not part of the original policy. He went to the insurance ombudsman who ruled in favor of the customer but the company has challenged the order before the High Court of Kerala.

Mahendran has not received the money on his insurance claim so far. The insurer insists that he had not sent the hospital discharge summary along with his claim. The laborer went to the hospital again and managed to get a duplicate copy of the summary. The divisional manager refuses to have a look at the copy.

All of them have fallen prey to insurance companies which pass on unjustifiable riders in fine print. Unsuspecting customers do not realize the catch until their hour of need. The tormentor of both Molly and Aniyamma is a public sector insurance firm trusted by thousands of people. Their experiences cast a shadow over the reputation enjoyed by the public sector.

The Insurance Regulatory and Development Authority (IRDA) has made it mandatory for insurers to supply the terms and conditions in plain language to the customers when they sell policies. Insurers, however, still get away after violating the norms. Naive customers continue to be cheated.

The companies seldom acknowledge their mistakes, as was evident in the doctor’s case. The ombudsman’s ruling clearly revealed the lapse from the part of the company in letting the customer know about the terms and conditions before selling a policy. The public sector company responded by suing the customer and the ombudsman.

The institution of ombudsman has been a check against the excess of the insurance companies because it provides a platform for the consumers to seek redressal of grievances without going through the technical measures and spending much money.

The company was not allowed by the High Court to pursue the case until it submitted before the court the amount it was told to pay to the doctor. The same company has lost a case against the ombudsman in the High Court but refuses to call it quits.

Its high time prospective buyers weigh each company by the treatment meted out to by it to its customers.

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